26 September 2007

"Universal PanderWhat are people really wishing for when they say they wish for a single nationalized health insurance program? Security. Our current employer-provided system means that most of us are just a pink slip away from losing our insurance coverage. It also means that, deprived of the bargaining power of large corporations and unions, the self-employed are left with fewer choices and higher premiums. Handing over the whole kit and kaboodle to the government is a seductively simple solution. But it would also be a very expensive solution.

The British are often held up as the standard to which we should aspire."

Arrgh! (sound of head exploding)

NOBODY is advocating for an NHS! Not even nut-job lefty elf Kucinich! NOBODY! Primarily that's because the NHS is a disaster. There are other reasons, too, but I'll leave it at that.

Also, you miss one major fact in your coda -- the UK spends less per capita, but not because UK citizens are dying and not utilizing their health care. The average life expectancy there is in fact longer. They spend less because they pay doctors less, have invested much much less in medical infrastructure, and cut corners on utilization of health care (from doctor visits, to simple labs, to heart caths to MRIs). The effect this has on outcomes has not been well established.

You are right, though, in your central point, I think: Universal health (or a government-run national health insurance) will do little to contain the exploding costs of health care. Universal Coverage and Cost Containment are two very different things, and I have not seen a proposal which adequately addresses both. I'm not sure it's really possible to address both in a single unified proposal. Even the most dramatic proposal, Medicare for all, would achieve only temporary reduction in cost due to a reduction in administrative costs, but would not inherently reduce the amount Americans spend on health care, or the growth in health care spending. HillaryCare and EdwardsCare and ObamaCare have only vague pretensions to cost control and focus primarily on expanding the number of people with access to health care.

Which is fine with me.

The crisis right HERE and NOW is the 48 million-plus Americans who have no access to medical care. The future crisis is the economic sustainability of the system. Both need to be addressed, but my preference is to fix the pressing humanitarian crisis first and then address the sustainability factor down the road. Honestly, not only is universal coverage more urgent, it's easier. There doesn't seem to be any easy solution to the cost growth -- there are too many variables, cultural factors, scientific questions, and interested stakeholders to allow for a quick & simple fix. There is, however, a number of quick & easy fixes to universal coverage.

So let's just get busy with that and figure out how we'll pay for it down the road.

"The crisis right HERE and NOW is the 48 million-plus Americans who have no access to medical care."

Actually that's just wrong. Walk into any ER and you'll be taken care of. (Of course that is not the best or most cost effective way to be taken care of.) What I think you mean is that these people have no 3rd party payor to pay for their care. And that is something entirely different.

Anon 3:47,With respect, you have no idea what you are talking about. Walk into an ER with dangerously elevated blood pressure, and you'll walk out with a piece of paper directing you to go get a doctor to get the blood pressure under control (after a work-up to rule out stroke, etc). Walk in with diabetes and you'll get a prescription for medicine which you probably can't afford and a referral to a primary care doctor (who may not see you without insurance). Come in with abdominal pain due to gall stones and you'll get some tests and a shot of pain medicine and be referred to a surgeon who won't operate without you getting some insurance.

We can apply the million-dollar band-aid, but other than in crisis situations, you can't get health care in the ER.

I admit uninsured patients with gallbladder attacks all the time. They get their gallbladders taken out the next day.

If someone can't afford a simple diabetes pill, then they should be able to qualify for existing Medicaid programs. Which is no guarantee that they will be able to find docs to take care of them long term. Then again, they won't have that guarantee with a single payer system either.

How much money is there to be saved by making preventative care available to the 48 million uninsured? Also, are there savings to be realized when those operating under the Bush/Anon 3:47 plan stop bothering the ER? Seriously, is there an efficiency improvement if they go to a GP instead?

The crisis right HERE and NOW is the 48 million-plus Americans who have no access to medical care.

It will never be possible to take “progressives” seriously on reform as long as you insist on peddling this canard.

At least half of these “48 million-plus Americans” fall into two categories: people who can afford coverage but choose not to buy it and people who are eligible for government aid but choose not to apply for it. Another 20% aren’t Americans at all. They are foreign nationals (both documented and undocumented).

I love the "choose" framing there -- it's all free market and personal responsibility woo hoo!

Bullshit. It's hard to take any conservative seriously who insists that people are in large numbers "choosing" not to have funding for health care. When family premiums are approaching $10,000 annually, insurance is essentially out of reach even for families with incomes well above the poverty line. Is it a "choice" -- well technically, yes, if you prioritize rent, food, phone, transportation, clothes, over health insurance it's a choice. But it's not a free choice, and not a rational choice.

Similarly with medicaid, it is true that there are a sizable number of people eligible who are unenrolled. Why? Not because they have "chosen" not to -- more likely because they are unaware of the option, or they are unsophisticated and ran into administrative roadblocks that they did not know how to overcome and just gave up. And even if they did sign up, I'm not sure what good it would do -- the state medicaid budgets are all overextended and in WA, every year they announce new cut-backs in eligibility. And where would all the doctors come from to treat these new medicaid patients? Most docs in our community stopped accepting new medicaid patients long ago.

Potemkin crisis, my ass. If you claim there is no crisis in access to health insurance/health care you are either being willfully blind or deliberately misleading.

We rarely admit simple symptomatic cholelithiasis. If the WBC is up, intractable pain, vomiting, abnl labs, etc, yeah we can admit for more urgent surgical treatment. But for those who are uncomplicated (insured or otherwise) it's usually a pain shot or two (or three), labs and ultrasound, and home with surgical follow-up. These do account for the majority of gallstone presentations.

Jim,

It's not clear to me that we would "save" money with universal coverage. Predictably, those with new access to care will utilize that access and costs will rise. There is an argument that society might recoup some of that cost with increased number of healthy and productive citizens, but that's speculative, I think.

Thanks for the data -- it reinforces my point. A family of four making $50,000 can in no way afford $11,000 in insurance premiums. (That's the most recent average premium cost according to the Kaiser Family Foundation.) So, given that fewer and fewer employers are providing health care as a benefit, more and more middle-class families are having to shoulder the full cost of insurance. Since the regressive tax code results in a $50,000 annual income yielding, what, $37,000 post taxes, that's almost 30% of take-home pay that would be consumed by insurance.

And you would claim that it's their "choice" not to purchase it. Nice.

Your link goes to a 2005 USA Today article that misrepresents the Kaiser findings. If you will take the time to read the Kaiser Foundation press release, you will find that it contains the following verbiage:

The average worker paid $2,713 toward premiums for family coverage in 2005 or 26% of the total health premium.

The latest survey shows that the cost has now risen to $3,281, nowhere near your $11K figure.

Which begs this question: How solid is an argument that relies on bogus stats?

The crisis right HERE and NOW is the 48 million-plus Americans who have no access to medical care.

I'll tell the people who run one of the large 3 free or reduced-priced clinics not including the grocery store clinics (if I have time, I'll tell one of the 6 charity dental clinics too) in a 3 mile radius of my hospital that not a single person who is uninsured still has access to medical care in this city. They'll be interested in knowing that their $20 fee to be seen is too much.

Carton- You certainly don't seem to be someone who has ever had to prioritize housing, food, clothing, etc over healthcare. As a recent college graduate, I have a lot of friends working for non-profits that can't affort health insurance but don't qualify for assisted care, or have insurance with such crappy coverage that they still can't afford to be seen. Adding student loans to that food/shelter burden can be a real bitch. It's absurd to act as though the availability of ER care, when you know that using it could drive you bankrupt, qualifies as "access to healthcare."

Nurse K- Having worked for a couple of free/reduced-price clinics, I agree that they are doing really important and great work. But they are more of a bandaid for a messed-up system than a real solution. The clinics I worked for offer a lot of care but also have pretty impressive limits. A huge portion of the uninsured patients we'd have to refer to specialists never ended up getting seen because those folks never bothered with developing a system to deal with the un and underinsured.

I am so tired of the pandering to the so called poor. I am so tired of mom bringing kids into the ER for a visit to get a tylenol prescription because "medicaid will pay for it". She digs the medicaid card (next to her Mexican ID card) out from the bottom of her purse underneath the IPOD, ringing cell phone, and keys to a new Explorer.

It is all bull....! We need to reduce the dependency, not create more of it. The government wants to be the big teat and there are to many people who are disgustingly willing to suck on it.

I am so tired of the pandering to the so called poor. I am so tired of mom bringing kids into the ER for a visit to get a tylenol prescription because "medicaid will pay for it". She digs the medicaid card (next to her Mexican ID card) out from the bottom of her purse underneath the IPOD, ringing cell phone, and keys to a new Explorer.

Well, anonymous 10:10, we are all tired of something I suppose. I'm tired of self-righteous bigots. I do have the comfort of knowing that (1) the tide is turning against those who've spent so long vilifying the poor and (2) Jesus is on my side. To quote Bill Murray, "whichisnice."

Upon further reflection, I wonder if anon 10:10 actually means these things. I suspect s/he may be a lefty trying to make the righties look bad. Hard to tell.

The "self righteousness" of the left makes me laugh. They love to be self righteous with what others have and that there can never be anything such as fraud waste and abuse. Jesus was not any government entity. Sure he taught that individuals should help the poor. I don't think he promoted dependency but instead promoted self responsibility. A hand up, not necessarily a hand out. Create a bunch of dependent people though and I guess you can advance your agenda by creating a generation of dependent helpless people, EH?

Shadowfax: in the absence of intractable pain, vomiting, fever, or elevated WBC, of course there is no absolute indication for cholecystectomy anyway. Dietary modification, yes. Antispasmodic medications, certainly. Avoiding the KFC and the enchiladas is a good first step.

I work at a national for-profit hospital. The poor get first rate care at our hospital even though there is a county hospital 1o miles away that recieves lots of government funding to do this job.

A STEMI gets a cardiac cath ASAP and a CABG if he needs it. Those out of meds get free hardship meds from the social worker. The hot gallbladder gets a cholecystectomy. The trauma patient gets a first rate trauma activation, scans, surgery, etc if needed. All of this at hospital and provider expense.

Shadowfax could write for generic diabetes meds and htn meds that can be filled at WalMart for 4$. BTW many of these people have these problems because of decades of self abuse, smoking, drinking, and supersized fast foods. Again, much of America has lost self respect and responsibility.

Anon made his fictional welfare queen Mexican in an effort to make her less sympathetic. True? Alright, well, that is the behavior of a racist. I did not read something into what s/he posted. The comment is on its face racist.

Anon,

I challenge you to find one pull yourself up by the bootstraps quote from Jesus. If you think it hurts the poor to provide them with food or healing, fair enough. It is not an irrational argument, but Jesus didn't think so.

Catron---You certainly don't seem to be someone who has ever had to prioritize housing, food, clothing, etc over healthcare.

Ah ... but I have. In my misspent youth. I was so poor that I push-started my VW (jumping inside to pop the clutch) for 6 months because I couldn’t afford a new battery. And I sure as hell didn’t have health coverage at that time. But it never occurred to me (not once) that the taxpayer owed me health care coverage, or anything else.

But that’s not the issue. the point is this: The “plight of the uninsured” has been wildly exaggerated by misguided people who think (despite all of the evidence) that our health care system will be more efficient and cheaper if we allow a bunch of government apparatchiks run the thing.

The “crisis” is largely fictional, and the proposed solution would be a disaster.

The Kaiser foundation study did make the distinction you cite, but it is irrelevant in the setting of someone whose employer does not offer or subsidize health insurance (or who is self-employed). The Kaiser study "bottom line" was the real cost of health insurance, which is the relevant figure in a discussion of "how much would it cost me to go out and buy this without someone else footing the bill."

So you are hung up on the "Mexican". It could just as well be Martian, Mongolian, African, or any combination of white trash.

I myself have Mexican, East Indian heritage along with a good dose of white trash. The truth is no less relevent when you call me a bigot, like scalpel says.

The point is that we don't need to be rewarding people for free ER visits for tylenol when they drive to the ER in a new Explorer, have an expensive cell phone plan, cable TV, spend 30$ a month on Itunes, and eat at the chuckwagon 10 times a week.

A couple of days ago a young woman on medicaid signed out against admission for a mild case of gallstone pancreatitis because she was going to Hawaii the next day. What the F? We are paying for her healthcare and she isplanning on a trip to Hawaii. My kids have been bugging me to go but I am responsibly saving for their college, paying our health and disability insurance, contributing to church and charity of my choice, and paying a bunch of taxes for those who choose to ride in the cart. Stop it.

Charity is wonderful on the part of individuals, churches, and organizations and I encourage it. However it is not the governments role to encourage dependency and helplessness.

So you are hung up on the "Mexican". It could just as well be Martian, Mongolian, African, or any combination of white trash.

Well, several of those would have also been bigoted. But you didn't randomly pick a nationality, you targetted a group of oppressed powerless people. So, again, I'm pretty much 100% okay with identifying your comment as racist, because, well, it was racist.

I myself have Mexican, East Indian heritage along with a good dose of white trash. The truth is no less relevent when you call me a bigot, like scalpel says.

Neither being Mexican nor serving underprivileged people gives you the right to disparage those people as a class. It does not insolate you from making racist comments. What is relevant about your comments is that they reveal a distasteful motivation behind what you say. So, when you make observations about people, I know it is colored by a racist framework.

The point is that we don't need to be rewarding people for free ER visits for tylenol when they drive to the ER in a new Explorer, have an expensive cell phone plan, cable TV, spend 30$ a month on Itunes, and eat at the chuckwagon 10 times a week.

If you believe there is a real need to address fraud in the medicare system, that is fine. I have no knowledge about how wide spread it is or how it compares to war profiteering or tax evasion as drains on the public treasure. If you are hung up on people having more than you think they ought to have, or living above the standard you'd like for them to live it is not fine. Your argument appeals to both sentiments.

Charity is wonderful on the part of individuals, churches, and organizations and I encourage it. However it is not the governments role to encourage dependency and helplessness.

The role of the government is to serve the governed. I am served by the social safety net because I am only able to tolerate people like you and I being paid 25 times as much for our work as the guys digging ditches because a social safety net exists.

Sure he taught that individuals should help the poor. I don't think he promoted dependency but instead promoted self responsibility. A hand up, not necessarily a hand out.

So, I'm guessing you didn't find any scripture to support this notion. If you'd like to read little into how Jesus felt about the poor you might want to check out Luke 16:19-31. It is pretty compelling stuff. Look and see if he says that the rich man should have told Lazarus to go get a job. I don't think it said that.

No one expects those who really can't work to work, but there are many who can, that don't. And once again, the rich man does not represent a government entitity, and Lazarus does not representing the able but lazy. The story is not about governmental policy but is a story regarding individual benevolence.

Thanks for tolerating me though. Work is too hard though, I think I will just go to your doorstep and beg.

There is nothing wrong with church and individual outreach as a hand up. But if the lefties would be honest with themselves they would see that welfare and other government programs for the poor have been a social failure. They do not lessen poverty, just perpetuate it. It is good fodder for votes though......to make promises you can't keep with someone elses money and to keep the masses dependent and hepless.

I really enjoyed reading your article. I found this as an informative and interesting post, so i think it is very useful and knowledgeable. I would like to thank you for the effort you have made in writing this article.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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